Thursday, April 12, 2012

Now, I Need Your Help

Hey all,

Hope everyone had a great Easter. I went to Miami and spent Easter with my wife's family (who I consider my family). We had a great time. One thing though: no one in my family likes golf. I sat in the living room and watched The Master's all by myself. It was awesome. Too bad I didn't have anyone to share it with. Their thing is baseball, so I can say I watched a ton of baseball.

Listen, I reread my last post and I think I might have misrepresented Triodent a little. Here is the thing: Triodent is getting bigger. They had something like 10 reps in the USA. One of the ways they were getting the word out about their products was by supporting lecturers (like me). And it worked; their products are doing very well. Recently they have come into an agreement with Ultradent to distribute their products. Seems like a win-win.

Now, on to the topic de jour. I want to ask some advice. You know dentists are basically on islands. Things like this help, but for the most part, most of us are doing things on our own. So, I don't know what is normal sometimes.

For instance, you take a tooth out and 4 weeks later there is a bone spicule sticking out of the patient’s gums. You go in there and take it out. Do you charge for something like this? Or, better yet, what if they have a dry socket? Not your fault. But next thing you know, you are changing dressing two, maybe three, times. All of this I do for free. But I have to tell you that I can't remember the last time someone came to me with a dry socket. It must have been over 6 years ago.

How about this? You do a deep filling. The tooth starts to hurt, so you relieve the occlusion (free). Then the tooth doesn't stop hurting. IT is throbbing and very tender to the touch. Uh oh. This bad boy needs a root canal. So you do the root canal and there are no problems there. Do you charge for the access filling?

Some of you would then recommend a crown (I think that if it was small enough to do a filling, just because it has an access filling doesn't mean it needs a crown, but we won't get into that). Do you charge for the build-up to fill in the hole left by the root canal? What if you do a crown and the same thing happens? Do you charge to fill the access hole?

What if you do a denture? We all know that there are two types of people that get dentures. The first type is the patient that you deliver the denture to, but then never see again (I have just read about this patient in books). The second type is the patient you deliver the denture to, and then this happens:

You ask if there are any high spots or areas that might be rubbing. The patient says that everything feels great. But, a week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

A week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

A week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

A week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

Here is the thing. My father says that 3 adjustments come with a new denture. Fine. But when do you tell the patient this? Before the denture is made? All you are doing is telling them that things may not be perfect, but give us three times to fix it. How about after you deliver the denture? Or do you tell them 3 adjustments are on the house after the second adjustment? Then it looks to the patient like you think he is crazy.

How about things like a baby tooth? If I have to take a tooth out on a 5 year old and it has big time root structure, that is easy. I charge them full $100. If the tooth is wiggling there and the parent wants you to take it out before it is naturally going to come out (even though you tell them that the thing is like a week away from coming out), what do you charge for that? If you go in there, put a 2x2 around it and take it out with your fingers, do you still charge $100? I think this is unfair and I guarantee they are going to think that, too. I think even $75 might be too much. I mean, the mom didn't even get a chance to sit down in the reception chair when the kid comes out.

I don't know. I know I am a wuss when it comes to valuing myself. What are you guys doing? I know I asked a lot of questions, but the more you answer, the better I (and other readers) will become.

6 comments:

Anonymous
said...

Don't the code guidelines offer a bit advice on some of those decisions? I'm still a student so I'm commenting on something I have no experience with and am probably wrong, but doesn't it specify a core buildup must contribute to retention? Isn't it clear that grabbing a primary tooth with some gauze is not a surgical extraction?

Okay, if the filling was done recently and it goes on to needing a root canal-i normally don't charge for access filling again. For a bony spicule and/or any aftermath of an extraction-no charge. I've seen plenty of cases with patient coming back thinking they have dry socket but only one true dry socket that resulted in a major distrust issue so i am glad you haven't seen dry socket in a long time.

Denture adjustments-unfortunately at no charge. There are four dentists in this office and this is the norm for this clinic. So i am just telling what we do. Might be different with different clinics.

Generally when I have to do something that is directly related to the work I have already done - eg. adjust the bite, sore spot on a denture,or do a second or even a third post operative visit for a surgical procedure, I DON'T CHARGE. If however, a new procedure is necessated (with the exception of dry socket if I have done an extraction - happened maybe 2 or 3 time in my 17 year career)such as a root canal on a sensitive filling, then I will charge. I will not charge for the access or occlusal resin, but I will charge if a post is required. Dentures are a bit of a problem - I also have patients that expect dentures to be 'warrantied' forever, even 3 or 4 years after delivery. I will charge only if I have to do some large adjustment or reline, but if it takes me 45 seconds to adjust a sore spot, I usually don't charge. Sometimes if they ask me too many questions about other thing going on in their mouth I charge for my time, unless it usually leads to more work. As far as pedo teeth are concerned, I will charge about 99% of the the time, unless the tooth is so loose the child could have pulled it out. You assume the liability of any sequelae if you take it out - you should be paid for that risk, and for your ability to take it out painlessly. But I disagree with you on one thing - I have seen far too many fractured teeth that were endodontically treated and did not have crowns. I almost always crown a posterior tooth with a root canal, unless it was occlusal access only and even then if the access is small. Great blog as usual, I always look forward to your words.KenJ (toronto)

I know a guy that you and I both know. He had an elderly patient who came in complaining of discomfort in their denture and asked him to fix the high spots. Like most dentists, he gladly obliged the patient for free. Then the patient came in the next week with the same complaint, and he against polished it down again for free with a denture bur. The patient gladly thanked him and case closed...until the patient came back the next week, and then the next week, and the next, and so on. Eventually the dentist realized that there was no possible way that this patient could have this much denture discomfort after 50 million free adjustments. He then concluded that since the patient was elderly and lived alone he was probably suffering from a case of loneliness rather than denture discomfort. The next time when the patient came in for the usual, the doctor then just turned his back while the patient was in the chair, hit the foot pedal to the hand piece "whrrrr whirr!" without actually touching the denture and then gave the denture back to the patient. "How does that feel?" he asked the patient. "Oh why thank you Doctor! That is much better! It feels perfect!"The patient then walked out the door and would come back in to the office from week to week. Our buddy would then do the same "adjustment" for free and the patient would kindly thank the doctor for his services and smile and leave.If you want to save some of your time on those multiple-returning lonely free-denture adjustment patients, just try the good ol' fashioned placebo effect.

I try and charge a fee for dentures that takes into account the patient may return several times for adjustments. If they are comfortable after delivery and do not return for adjustments, all the better for everyone.

When I noticed this among my patients, I started leaving a collection of brochures about nearby community and support groups in the reception area. I've never seen anyone pick them up but they seem to surreptitiously go. I also leave other health information that people find difficult to talk about eg prostate cancer, depression, Alzheimer's .They take up little space.

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